INTRODUCTION TO EVALUATION AND … to Evaluation and Management Psychiatrist

Introduction to Evaluation and Management (E/M) Coding for the Child and Adolescent Psychiatrist

Copyright © 2012 by the American Academy of Child and Adolescent Psychiatry. CPT is a registered trademark of the

American Medical Association.

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INTRODUCTION TO EVALUATION AND MANAGEMENT (E/M)

CODING FOR THE CHILD AND ADOLESCENT PSYCHIATRIST

Benjamin Shain, MD, PhD

David Berland, MD

Sherry Barron-Seabrook, MD

Copyright © 2012 by the

American Academy of Child and Adolescent Psychiatry

OVERVIEW

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E/M Learning Tips • Recognize that there is a

lot of information and it is likely not something you can learn without effort

• Go through this presentation and others first with an eye to learning the system rather than rather than remembering details

• Later, “cheat sheets” and templates may be helpful.

• Memorize portions related to the small number of codes you use every day

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What are E/M Codes? • Code starts with “99” • Used to report a medical

service rendered during a patient visit

• Evaluation (collecting and assessing information) and Management (planning treatment or further assessment; prescribing medication)

• Used by all physicians and other medical providers

• May be reported in addition to a “procedure” unless specifically restricted

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Why use E/M? • They pay more for the same

service

• For most psychiatrists there will be no choice starting in 2013

• But, – Aren’t these codes

complicated, hard to document, easy to miscode, and vulnerable to audit? • Yes, yes, yes, yes

• We believe this series of webinars will give you the information you need to code in confidence

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PAYMENT

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Medicare Payments

Code Payment

90862 $58.54

99211 $19.74

99212 $42.55

99213 $70.46

99214 $104.16

99215 $139.89

Code Payment

90801 $152.49

90802 $166.10

99204 $160.66

99205 $199.46

99222 $133.09

99223 $195.38

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In Other Words…

Code Payment

90862 $58.54

99211 $19.74

99212 $42.55

99213 $70.46

99214 $104.16

99215 $139.89

• Medicare payment for 99213 is 20% more than it is for 90862 and, for 99214, is 78% more

• Payments from other payers may be similarly more

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DOCUMENTATION

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E/M Documentation Guidelines • 1995

– First expansion of CPT manual

• 1997 – Spells out the elements of a general multi-system

exam and 11 single organ system exams • Included in these is a single system psychiatric examination

– Download: http://www.cms.gov/medicare/

• Voluntary auditing guidelines

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Reason for Documentation

• Facilitates: – The ability to evaluate

and plan the patient's immediate treatment and to monitor his/her health care over time

– Communication and continuity of care among health care professionals

– Appropriate utilization review and quality of care evaluations

– Collection of data that may be useful for research and education

– Accurate and timely claims review and payment

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http://www.cms.gov/medicare/




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General Principles of Documentation

• Complete and legible

• Include:

– Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results

– Assessment, clinical impression or diagnosis

– Plan for care

– Date and legible identity of the observer

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General Principles of Documentation

• Rationale for ordering ancillary services should be easily inferred

• Past and present diagnoses should be accessible

• Appropriate health risk factors should be identified

• Document the patient's response to, changes in treatment, and revision of diagnosis

• The CPT and ICD-9-CM codes reported should be supported

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General Audit Issues • Upcoding • Downcoding • Meet E/M criteria • Medical necessity • Red flags

– High use of highest level code – Exclusive use of one level code

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CODING STRUCTURE

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E/M Families • Most E/M codes are part of “families”

– Site of service, for example • Office • Hospital • Nursing facility • Emergency department

– Patient status, for example • New • Established • Day of discharge • Consultation

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Levels

• Most families have multiple levels

–Denoted by the 5th digit of the code

–3 or 5 levels are commonly used

–We will now focus on choosing and documenting the appropriate level

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E/M Components • History • Examination • Medical decision making • Counseling • Coordination of care • Time • Nature of presenting problem

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KEY COMPONENT OVERVIEW

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History • Chief complaint • History of present

illness (HPI) – Elements – Chronic or inactive

problems

• Past, family, social history (PFSH) – Past history – Family history – Social history

• Review of systems (ROS) – 14 organ systems

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Physical Examination

• Psychiatric single system examination

– Constitutional

– Psychiatric (mental status)

– Musculoskeletal

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Medical Decision Making

• Number of diagnoses or management options

• Amount and/or complexity of data to be reviewed

• Risk of complications and/or morbidity or mortality, related to

– presenting problem,

– diagnostic procedure, or

– management option

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HISTORY DETAIL

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History

• Chief Complaint

• History of Present Illness

• Past, Family, and Social History

• Review of Systems

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Chief Complaint • Only 1 level, but all levels of history require • CC states the reason for the encounter

– May be from the provider perspective, e.g., • Main symptom(s) • Follow up visit for …

– May be from the patient perspective, e.g., • “I cry too much.” • “My mother told me to come.”

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HPI Description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.

Elements: • Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated signs and

symptoms

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HPI Example The patient reports intermittent1 emotional2 problems of moderate3 sadness4 starting with a romantic breakup5 six months ago6, now more so when alone7 and associated with poor sleep and appetite8.

1. Timing 2. Location 3. Severity 4. Quality 5. Context 6. Duration 7. Modifying factors 8. Associated signs and

symptoms

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HPI Levels

• Brief

– 1-3 elements OR

– Status of 1-2 chronic or inactive conditions

• Extended

– 4 or more elements OR

– Status of at least 3 chronic or inactive conditions

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Past, Family and/or Social History (PFSH) • Past history

– Illnesses

–Operations

– Injuries

–Treatments

• Family history –Medical events in

patient’s family

• Social history –Past and current

activities

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Past, Family and/or Social History (PFSH) • Pertinent

– Item from 1 area

• Complete

– Item each from 2 areas (established patient)

– Item each from all 3 areas (new patient)

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Review of Systems

• Constitutional

• Eyes

• Ears, Nose, Mouth, and Throat

• Cardiovascular

• Respiratory

• Genitourinary

• Musculoskeletal

• Gastrointestinal

• Integumentary (skin and/or breast)

• Neurological

• Psychiatric

• Endocrine

• Hematologic and Lymphatic

• Allergic/Immunologic

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Review of Systems • Problem pertinent: System

directly related to the problem(s) identified in the HPI

• Extended: 2-9 systems

• Complete: 10 or more systems – Document individually

systems with positive or pertinent negative responses

– “All other systems reviewed and are negative” is permissible

– In the absence of such a notation, at least 10 systems must be individually documented

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History Type

HPI PFSH ROS Type

Brief N/A N/A Problem focused

Brief N/A Problem

pertinent

Expanded problem

focused

Extended Pertinent* Extended Detailed

Extended Complete Complete Comprehensive

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*No PFSH required with subsequent hospital visits

History Type HPI PFSH ROS Type

1-3 elements or 1-2

chronic

N/A N/A Problem focused

1-3 elements or 1-2

chronic

N/A 1 system Expanded problem

focused

4 elements or

3 chronic

1 element* 2-9 systems Detailed

4 elements or

3 chronic

3 elements** 10-14

systems

Comprehensive

35 *No PFSH required with subsequent hospital visits **2 elements for established patients

PHYSICAL EXAMINATION DETAIL

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Physical Examination

• Cardiovascular • Ears, nose, mouth

and throat • Eyes • Genitourinary

(female) • Genitourinary (male)

• Hematologic, Lymphatic, Immunologic

• Musculoskeletal • Neurological • Psychiatric • Respiratory • Skin

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Psychiatric Exam Constitutional (shaded box) • Three vital signs:

– Sitting or standing blood pressure

– Supine blood pressure – Pulse rate and regularity – Respiration – Temperature – Height – Weight

• General appearance of patient, e.g.: – Development

– Nutrition

– Body habitus, deformities

– Attention to grooming

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Psychiatric Exam Musculoskeletal (unshaded box) • Assessment of muscle

strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

• Examination of gait and station

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Psychiatric Exam Mental Status (shaded box) • Speech

• Thought process

• Associations

• Abnormal or psychotic thoughts

• Judgment and insight

• Orientation

• Recent and remote memory

• Attention span and concentration

• Language

• Fund of knowledge

• Mood and affect

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Psychiatric Examination

Level of Exam Perform and Document

Problem Focused 1-5 elements identified by a bullet

Expanded Problem

Focused

At least 6 elements identified by a bullet

Detailed At least 9 elements identified by a bullet

Comprehensive Perform all elements identified by a bullet; document every

element in each box with a shaded border and at least one

element in each box with an unshaded border 42




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MEDICAL DECISION MAKING DETAIL

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• Number of diagnoses or management options

• Amount and/or complexity of data to be reviewed

• Risk of complications and/or morbidity or mortality

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2/3 elements must be met or exceeded

Number of Diagnoses or Management Options • Based on

– Number or types of problems addressed during the encounter

– Complexity of establishing a diagnosis

– The management decisions that were made

• Other indicators – Problem undiagnosed

– Number or types of tests ordered

– Need for consultation

– Problem worsening

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Number of Diagnoses or Management Options • Minimal

• Limited

• Multiple

• Extensive

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Problem Points

Category of Problems/Major New symptoms Points per problem

Self-limiting or minor (stable, improved, or worsening) (max=2) 1

Established problem (to examining physician); stable or improved 1

Established problem (to examining physician); worsening 2

New problem (to examining physician); no additional workup or diagnostic procedures ordered (max=1)

3

New problem (to examining physician); additional workup planned* 4

47 *Additional workup does not include referring patient to another physician for future care

Number of Diagnoses or Management Options

Level Total Problem Points

Minimal 0-1

Limited 2

Multiple 3

Extensive 4

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Amount and/or Complexity of Data to be Reviewed • Types of diagnostic tests

ordered

• Review of old medical records – Document the relevant

findings

• History from other sources – Document the relevant

findings

• Discussion of test results with physician who interpreted the test

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Amount and/or Complexity of Data to be Reviewed • Minimal or None

• Limited

• Moderate

• Extensive

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Data Points Categories of Data to be Reviewed (max=1 for each) Points

Review and/or order of clinical lab tests 1

Review and/or order of tests in the radiology section of CPT 1

Review and/or order of tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from someone other than patient 1

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

2

Independent visualization of image, tracing, or specimen itself (not simply review report)

2

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Amount and/or Complexity of Data to be Reviewed

Level Total Data Points

Minimal or None 0-1

Limited 2

Moderate 3

Extensive 4

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Risk of Significant Complications, Morbidity, and/or Mortality • Based on risks

associated with the presenting problem, diagnostic procedure, and the possible management options

• The highest level of risk in any one of these categories determines the overall risk

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Table of Risk Level of

risk

Presenting problem(s) Diagnostic

procedure(s)

ordered

Management

options selected

Minimal One self-limited or minor problem Venipuncture;

EKG; urinalysis

Rest

Low Two or more self-limited or minor problems;

One stable chronic illness;

Acute uncomplicated illness

Arterial

puncture

OTC drugs

Moderate One or more chronic illnesses with mild exacerbation,

progression, or side effects;

Two or more stable chronic illnesses;

Undiagnosed new problem with uncertain prognosis;

Acute illness with systemic symptoms

Prescription drug

management

High One or more chronic illnesses with severe exacerbation,

progression, or side effects;

Acute or chronic illnesses that pose a threat to life or bodily

function

Drug therapy requiring

intensive monitoring for

toxicity

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Number of

diagnoses or

management

options

Amount and/or

complexity of

data

Risk Complexity of

decision making

Minimal Minimal or

None

Minimal Straightforward

Limited Limited Low Low

Multiple Moderate Moderate Moderate

Extensive Extensive High High

2/3 elements must be met or exceeded:

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Problem

Points

Data

Points

Risk Complexity of

Medical Decision

Making

0-1 0-1 Minimal Straightforward

2 2 Low Low

3 3 Moderate Moderate

4 4 High High

2/3 elements must be met or exceeded:

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TIME

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“Typical” Time

• Guide when code level is determined by key components

• Actual time may be more or less

• This system rewards efficiency

• No need to track or document

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Counseling and/or Coordination of Care Exception • Counseling and/or

coordination of care is more than 50% of the time of the encounter

• Time becomes the controlling factor – Face-to-face time for office

visits

– Unit time for facility visits

• Document – Length of time of the

encounter and of the time spent in counseling and coordination of care

– The counseling and/or coordination of care activities

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Counseling

• Discussion of – Diagnostic results

– Impressions

– Recommended diagnostic studies

– Prognosis

– Risks and benefits of management options

– Instructions for management and/or follow-up

– Importance of compliance with chosen management options

– Risk factor reduction

– Patient and family education

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Code by Type of Visit

• Driven by complexity of medical decision making – Acute medical problems

– Managing chronic conditions

• Exceptions – “Check up”

• After gap in treatment

• Stable patient requires careful monitoring

– Counseling and/or coordination of care are greater than 50% of the time of the visit

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New and Established Patient • New patient

– Not seen within the past 3 years

• Established patient

• Seen within the past 3 years

• “Seen”

– Exact same specialty and subspecialty

– Same group practice.

– Covering same as covered

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That’s It for Now!

• Please view other AACAP presentations for application of specific E/M codes to patient examples and other CPT coding topics

• Questions sent to Jennifer Medicus at [email protected] will be passed on to the AACAP CPT Coding Subcommittee.

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INTRODUCTION TO EVALUATION AND … to Evaluation and Management Psychiatrist